Provider Demographics
NPI:1073637450
Name:COGHLAN, CHARLES Y (DMD, MSD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:Y
Last Name:COGHLAN
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 E LAMPKINS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-9726
Mailing Address - Country:US
Mailing Address - Phone:812-339-8508
Mailing Address - Fax:
Practice Address - Street 1:2911 E COVENANTER DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6320
Practice Address - Country:US
Practice Address - Phone:812-332-9269
Practice Address - Fax:812-335-9052
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006549A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics